Collegial conversations with a Balinese doctor

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VOL 60: MARCH • MARS 2014

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Canadian Family Physician Le Médecin de famille canadien

267 Reflections

Collegial conversations with a Balinese doctor

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everal summers ago I had a wonderful opportu- nity to travel to Bali with my family for a mini sab- batical. After 30 years of medical practice, I was looking forward to a break from my hectic professional routine of balancing urban family practice, academic medicine, and family life.

A sublime and serendipitous setting

I chose the gracious rural village of Penestan in central Bali as a retreat for the beginning of our family journey.

Penestan is a sublime setting of tropical ridges of palm, papaya, and tamarind trees; rice terraces; and vibrant traditional village life, against the backdrop of distant volcanoes. Penestan is the cultural home of Balinese painters and dancers and where many romantic myths about Bali were born. A destination over the years for European artists and vacationing celebrities, Penestan has also drawn cultural scholars such as anthropologist Margaret Mead and Canadian ethnomusicologist and composer Colin McPhee.

Our home for the frst week of travel was a resort in Ubud, a collection of traditional guest houses set among the rice terraces. My intention was to leave medical life behind for a while, but the presence of a small sign,

“Dr D. Swandewi,” next door to our teak villa intrigued me. I approached this small pavilion of a medical offce and tried to imagine my Indonesian colleague’s medical life in the equatorial heat. What kind of health problems did Dr Swandewi treat and what was medical practice here like? When I entered the waiting room a young Balinese woman in a sarong greeted me and asked if I would like to see the doctor. I introduced myself, business card in hand, and quickly learned I was speaking to the doctor herself. This simple introduction was soon to lead to a fascinating week of collegial conversations.

My Balinese colleague

Before long, I had learned that Dr Swandewi—or Dewi, as she asked us to call her—was an emergency physician who practised in the local regional hospital in Gianyar, just 1 hour away from her offce in Penestan.

She had been in practice for more than 10 years. The resort villa was her family’s business. When she was not working at the hospital, she ran her offce near the guest houses as a small primary care practice. Dewi proudly told me that her mother had been the sole midwife for the Penestan region and had used this same office for her midwifery practice until she retired in

Michael Roberts

MD CCFP FCFP 1981. Dewi’s mother and father saved the income from her mother’s clinical work to build the guest houses as a retirement business.

Our conversation began with the usual medical chit- chat about the kind of patients and health conditions we treated. I learned that in the emergency department in Gianyar a dog bite was considered a rabies case unless proven otherwise, and that the differential diagnosis for a patient with a fever included dengue fever and malaria. But soon our conversation turned to a more pressing topic.

Tomorrow would be Galungan, the Balinese festival for departed ancestors. Every 210 days, the Balinese ready their lives for the return of the spirits of their ancestors by preparing a symbolic meal and temple offerings in the family temple. Dewi invited my teen- age children to help with making rice offerings for the upcoming holiday.

Our conversations soon moved to personal stories punctuated by clinical vignettes as we were shown how to combine bits of coconut, rice, incense, and fragrant spices onto a banana leaf as a temple offering. We were also taught how to create penjor—great soaring symbols uniting heaven and earth erected as welcoming talis- mans to each Balinese home. Dewi became our friend and was our guide to the intricacies of Balinese culture.

We were now in the know on where to fnd a temple procession and had learned the meaning of some of the Hindu symbols encountered in village life.

Exchanging stories

As our festival preparations continued, Dewi introduced me to her mother, the great local midwife of the community. Nyoman Suryani exuded a regal balance of inner strength, gentleness, and humour. As I watched this wise woman making offerings with her family, I could picture her in her role as a committed midwife to her community through 40 years of service. Nyoman was delighted to meet a medical colleague from overseas and to speak about her years caring for the women of rural Penestan and from the surrounding countryside. She laughed as she told bittersweet and suspenseful stories about chal- lenging clinical situations, such as the delivering of twins, late-for-dates deliveries, and local villagers arriving at her offce in labour without having had any prenatal care.

She was relieved to be retired now but keenly interested in discussing the latest developments in prenatal care and the history of midwifery in Canada.

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Refections

As our conversation proceeded, Dewi and Nyoman gave each other a knowing wink.

We soon found ourselves invited to a personal family ritual. Six weeks earlier, Dewi’s sister had given birth to Ketut. The family asked us to join them in a family rite of pas- sage, a naming ceremony for the baby.

The Balinese believe that when a baby is born, there are 4 births—that of the baby, the umbilical cord, the amniotic fuid, and the placenta. The Balinese revere the vehi- cles that have supported the life of the soon-to-be-born infant, so they have created a ritual to honour them.

In keeping with tradition, the ceremony for Ketut’s naming was conducted by a river.

We stood with the mother, father, baby, and immediate family as a high priest offciated.

On the riverbank, the priest lit a fre, then put the umbilical cord, kept for this occasion, into the fames, symbolically releasing it from its function. The saved placenta was next hon- oured, as the “brother” or “sister” to the infant.

The grandfather then played an exquisite rhythm on his gamelan before the baby was given her name. What a contrast to our North American approach to the birth of a child and the frequent lack of reverence for the role of the umbilical cord and the placenta.

Dewi and Nyoman asked many questions about our “rituals” and medical practices surrounding birth, such as circumcision and placental research.

Our visit to Bali was deeply personalized by our connection with Dewi and her family.

A casual collegial introduction had resulted in an invitation to join a special family moment in Balinese life. In the days that fol- lowed the naming ceremony, our enjoyment of our time hiking in the rainforest, explor-

ing local temples and archeological sites, wandering through art galleries, and watching Balinese dance per- formances was heightened by our lovely visits with the Suryani family.

Road trips and housecalls

The highlight of our week in Penestan was going out with Dewi as she ran family errands. She took us with her as she made social “housecalls,” giving us the privi- lege of meeting local people whose children had either been delivered by Nyoman or treated by Dewi as a local family physician.

Our journeys in her small car took us on a pilgrim- age through the splendour of Bali, driving on precipi- tous mountain ridges, amid dazzling rice terraces built

on the slopes, through forests of teak and mahogany, and passing scenes of traditional village life—farmers planting and harvesting rice, vendors selling luscious piles of mango, jackfruit, and passion fruit—until we arrived at the doors of her patients’ homes. We would be welcomed with respect, even reverence, greeted by a small bow. We sipped the water offered to us from regu- larly refreshed pitchers as we listened to the tales Dewi translated for us, of how she or her mother healed or delivered a family member of our hosts.

Between visits, Dewi spoke of the most common concern for all emergency doctors, trauma: automobile and motorcycle accidents were a persistent challenge for her as a physician, as they are for emergency care doctors in Canada. In Bali few motorcycle drivers wear helmets, and the mopeds and motorcycles negotiating

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269 Refections

these narrow Balinese roads could be loaded up with anything from a young family of 4 or a bundle of chick- ens to jerry cans of cooking fuel and unwieldy mat- tresses. As we drove, we were reminded of the risks car drivers take, too, in overtaking each other and passing on the roads’ treacherous curves, as we faced these risks ourselves.

During the week, Dewi and I moved on to talk about community health. Dewi told me that many HIV-positive prostitutes in the region were now being treated for newly acquired sexually transmitted infections, and Dewi and her colleagues had discovered that these women had little knowledge or understanding about how these infections were transmitted or of HIV’s deadly risks.

Our conversation then progressed to a discussion of medical education. There was no medical school in Bali. Dewi had gone to Jakarta for her training and spent her internship in Lombok. The average medical training course was 4 years of postsecondary school.

Finally we came to the delicate and perennially inter- esting topic of how well we were remunerated. She told me the average annual income for an Indonesian physician was equivalent to about $40 000. The medical profession was well respected by the public, but the national and provincial governments had a certain degree of antipathy toward the organized medical profession. A familiar story indeed; so often our governments viewed

our profession as self-serving rather than as serving the public’s well-being.

Heading north

All too soon my family’s blissful week in central Bali drew to a close; we prepared to set off to the north. Our time in Bali had been immeasurably enriched by our chance meeting and connection with Dewi.

What a pleasure to be of a guild that allowed me and Dr Swandewi, after a brief introduction, to con- verse so collegially about our professional and personal lives in Bali and Canada. These conversations with my Balinese colleague did not take place in a physician’s lounge or standing by a coffee cart. Instead, we shared our perspectives traveling through magnifcent vistas of bamboo groves and fligree waterfalls—or as we waited while a meandering water buffalo or a farmer and his herd of ducks crossed the road. Our acquaintance and fascinating exchange of stories and experiences have given me memories that I will savour and refect upon for years to come.

Dr Roberts is a community-based family physician in Toronto, Ont, Assistant Professor in the Department of Family and Community Medicine and the Dalla Lana School of Public Health at the University of Toronto, and the Professional Development Coordinator for the Ray D. Wolfe Department of Family Medicine at Mount Sinai Hospital.

Competing interests None declared